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Improved technique for hilar vascular stapling
Improved Technique for Hilar Vascular Stapling David J. Sugarbaker, MD, and Steven J. Mentzer, MD Division of Thoracic Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
The use of stapling instruments is common in thoracic surgery, but there is a continued reluctance to use them on hilar vascular structures. We have developed a technique that satisfies the major objections to stapler use on hilar vascular structures. (Ann Thoruc Surg 1992;53:265-6)
0
ver the last decade thoracic surgeons have become proficient in the use of surgical stapling instruments [l-31. There is continued reluctance to use stapling devices on hilar vascular structures, however. This reluctance arises from two principal concerns. The first concern is the act of faith involved in cutting on a closed stapling device, particularly when it has been applied to the pulmonary artery, and trusting when opening the device that staples have, indeed, been fired. Every surgeon has anecdotal experience of misfired staples leading to prolonged bleeding from the pulmonary artery and requiring sutures. The second objection arises from the need to remove and then replace the stapler under the pulmonary artery or pulmonary vein after a previous staple line has been placed. Fear of the so-called "postage stamp effect," which may cause a vascular tear, has prevented many surgeons from attempting a second placement of the stapler. We have developed a simple technique for vascular stapling that we believe addresses these major objections to its use.
Technique
Fig 1 . The Semm clamp carries a silk ligature behind the pulmonary artery or vein.
the vascular stapler is closed, appropriate precautions are taken to be sure the appropriate staple length has been attained, and then the stapler is fired (Fig 2). After this, three maneuvers are required to open the stapler. First, the pin is retracted; second, the lever is opened from behind and the safety placed; and last, the jaws are opened. Next, to place the second staple line in order to cut on the anvil and avoid disturbing the cardiac
Step one is to dissect adequately the main pulmonary artery or main pulmonary veins from the surrounding tissues for approximately 1.5 cm (Fig 1).With the pulmonary artery a 1-0 silk suture is then placed around the major vessel using a Semm suture carrier instrument. Great care is taken to avoid opening or closing the instrument while it is securely behind the pulmonary artery to prevent inclusion of the vascular wall in the clamp. After a ligature is placed in a clamp, the clamp is passed behind the vascular structure and the suture pulled from its tips (see Fig 1). Next, the suture is pulled away from the cardiac side of the vascular structure, gently snugging up and lengthening the segment of vascular wall exposed. A reloadable, disposable stapler (Ethicon, Somervilie, NJ) is then placed behind the structure in position. After the pin is secured, Accepted for publication Oct 1, 1991 Address reprint requests to Dr Sugarbaker, Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.
0 1992 by The Society of Thoracic Surgeons
Fig 2 . The stapler is in position to staple the cardiac side of the vessel. Gentle traction is placed upon the vessel using the silk suture.
0003-4975/92/$3.50
166
Ann Thorac Surg 1992;53:16%
HOW TO DO IT
SUGARBAKER AND MENTZER HILAR VASCULAR STAPLING
Fig 3 . The spent cartridge is removed by means of a right-angle clamp.
staple line, a right-angle clamp is used to remove the reloadable stapling cartridge (Fig 3). At this time, a new cartridge is dipped in saline solution to lubricate it and is placed in the upper jaws of the vascular stapler. The stapler is then shifted (Fig 4) and the 1-0 silk ligature is passed around through the jaws of the stapler to put tension on the proximal pulmonary artery or pulmonary vein. This attains a sufficient cuff of vessel distal to the clearly observable cardiac staple line. At this time, the jaws are closed and the stapler is fired; the anvil is used as
Heart
Fig 5 . The second staple line has been fired and the vessel is transected with the knife supported on the anvil.
a cutting surface for the second and less important distal staple line (Fig 5).
Comment This technique allows the surgeon to satisfy both potential objections to vascular hilar stapling. By using the 1-0 silk suture and the reloadable cartridge, the surgeon need only place the stapler once in the application of two vascular staple lines. The first of these staple lines is placed on the cardiac side. Opening the stapling jaws allows for careful inspection of this staple line before cutting the vascular structure. The second staple line is used to permit faster and easier cutting on the anvil while visualizing the cardiac staple line. The use of the reloadable stapler prevents the need for replacement of the stapling device after a previous staple line has been fired, thereby avoiding the “postage stamp effect.” The use of the 1-0 silk ligature allows healthy traction to be placed on the vascular structure after the cardiac staple line has been applied, therefore assuring that the surgeon is better able to obtain an adequate cuff on this staple line. We have successfully used this stapling technique in more than 100 patients undergoing pneumonectomy over a 3%-year period. We believe the technique preserves the advantages of stapling while satisfying the surgeon’s need to handle the pulmonary artery and veins gently during pneumonectomy.
References
Fig 4 . The stapler is repositioned and reloaded on the lung side of the vessel. This position allows careful inspection of the staple line on the cardiac side.
1. Forrester-Wood CP. Bronchopleural fistula following pneumonedomy for carcinoma of the bronchus. Mechanical stapling versus hand suturing. J Thorac Cardiovasc Surg 1980;80.40&9. 2. Steichen FM, Ravitch MM. Stapling in surgery. Chicago: Year Book Medical, 1984:1418. 3. Ravitch MM, Steichen FM.Principles and practice of surgical stapling. Chicago: Year Book Medical, 19871539.
The use of stapling instruments is common in thoracic surgery, but there is a continued reluctance to use them on hilar vascular structures. We have developed a technique that satisfies the major objections to stapler use on hilar vascular structures. (Ann Thoruc Surg 1992;53:265-6)
0
ver the last decade thoracic surgeons have become proficient in the use of surgical stapling instruments [l-31. There is continued reluctance to use stapling devices on hilar vascular structures, however. This reluctance arises from two principal concerns. The first concern is the act of faith involved in cutting on a closed stapling device, particularly when it has been applied to the pulmonary artery, and trusting when opening the device that staples have, indeed, been fired. Every surgeon has anecdotal experience of misfired staples leading to prolonged bleeding from the pulmonary artery and requiring sutures. The second objection arises from the need to remove and then replace the stapler under the pulmonary artery or pulmonary vein after a previous staple line has been placed. Fear of the so-called "postage stamp effect," which may cause a vascular tear, has prevented many surgeons from attempting a second placement of the stapler. We have developed a simple technique for vascular stapling that we believe addresses these major objections to its use.
Technique
Fig 1 . The Semm clamp carries a silk ligature behind the pulmonary artery or vein.
the vascular stapler is closed, appropriate precautions are taken to be sure the appropriate staple length has been attained, and then the stapler is fired (Fig 2). After this, three maneuvers are required to open the stapler. First, the pin is retracted; second, the lever is opened from behind and the safety placed; and last, the jaws are opened. Next, to place the second staple line in order to cut on the anvil and avoid disturbing the cardiac
Step one is to dissect adequately the main pulmonary artery or main pulmonary veins from the surrounding tissues for approximately 1.5 cm (Fig 1).With the pulmonary artery a 1-0 silk suture is then placed around the major vessel using a Semm suture carrier instrument. Great care is taken to avoid opening or closing the instrument while it is securely behind the pulmonary artery to prevent inclusion of the vascular wall in the clamp. After a ligature is placed in a clamp, the clamp is passed behind the vascular structure and the suture pulled from its tips (see Fig 1). Next, the suture is pulled away from the cardiac side of the vascular structure, gently snugging up and lengthening the segment of vascular wall exposed. A reloadable, disposable stapler (Ethicon, Somervilie, NJ) is then placed behind the structure in position. After the pin is secured, Accepted for publication Oct 1, 1991 Address reprint requests to Dr Sugarbaker, Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.
0 1992 by The Society of Thoracic Surgeons
Fig 2 . The stapler is in position to staple the cardiac side of the vessel. Gentle traction is placed upon the vessel using the silk suture.
0003-4975/92/$3.50
166
Ann Thorac Surg 1992;53:16%
HOW TO DO IT
SUGARBAKER AND MENTZER HILAR VASCULAR STAPLING
Fig 3 . The spent cartridge is removed by means of a right-angle clamp.
staple line, a right-angle clamp is used to remove the reloadable stapling cartridge (Fig 3). At this time, a new cartridge is dipped in saline solution to lubricate it and is placed in the upper jaws of the vascular stapler. The stapler is then shifted (Fig 4) and the 1-0 silk ligature is passed around through the jaws of the stapler to put tension on the proximal pulmonary artery or pulmonary vein. This attains a sufficient cuff of vessel distal to the clearly observable cardiac staple line. At this time, the jaws are closed and the stapler is fired; the anvil is used as
Heart
Fig 5 . The second staple line has been fired and the vessel is transected with the knife supported on the anvil.
a cutting surface for the second and less important distal staple line (Fig 5).
Comment This technique allows the surgeon to satisfy both potential objections to vascular hilar stapling. By using the 1-0 silk suture and the reloadable cartridge, the surgeon need only place the stapler once in the application of two vascular staple lines. The first of these staple lines is placed on the cardiac side. Opening the stapling jaws allows for careful inspection of this staple line before cutting the vascular structure. The second staple line is used to permit faster and easier cutting on the anvil while visualizing the cardiac staple line. The use of the reloadable stapler prevents the need for replacement of the stapling device after a previous staple line has been fired, thereby avoiding the “postage stamp effect.” The use of the 1-0 silk ligature allows healthy traction to be placed on the vascular structure after the cardiac staple line has been applied, therefore assuring that the surgeon is better able to obtain an adequate cuff on this staple line. We have successfully used this stapling technique in more than 100 patients undergoing pneumonectomy over a 3%-year period. We believe the technique preserves the advantages of stapling while satisfying the surgeon’s need to handle the pulmonary artery and veins gently during pneumonectomy.
References
Fig 4 . The stapler is repositioned and reloaded on the lung side of the vessel. This position allows careful inspection of the staple line on the cardiac side.
1. Forrester-Wood CP. Bronchopleural fistula following pneumonedomy for carcinoma of the bronchus. Mechanical stapling versus hand suturing. J Thorac Cardiovasc Surg 1980;80.40&9. 2. Steichen FM, Ravitch MM. Stapling in surgery. Chicago: Year Book Medical, 1984:1418. 3. Ravitch MM, Steichen FM.Principles and practice of surgical stapling. Chicago: Year Book Medical, 19871539.